Medical Assessment of the Drug Endangered Child. Instructor

Transcription

1 Medical Assessment of the Drug Endangered Child Instructor

2 Course Overview and Objectives Understand Methamphetamine and it s Effects Understand the Health Hazards of the Meth Lab Environment Understand the General Abuse and Neglect Issues Learn the Standard Medical Protocol for Drug Endangered Children

3 Methamphetamine and It s Effects Physiology Metabolism Effects on Adults Effects on Children

4 Physiology General Overview Neurotransmitters Dopamine and Dopamine Receptors

5 How Methamphetamine works in the brain Parts of the brain affected by methamphetamine

6 Normal Nerve Cell Nerve Cell

7 M Meth Nerve on Cell the Brain Nerve Cell M M M M M M M M Nerve Cell Nerve Cell

8 Metabolism Ingested, Smoked, IV, Oral Half-life is variable (4-24 hrs) Metabolized by the liver Excreted in the urine 1/3 of meth is excreted in active form as meth

9 Medical Effects of Methamphetamine Adults Short term Long term Permanent Children Short term Long term

10 Effects on Adults Short-term Increased energy, sexual arousal, euphoria Decreased appetite Increased heart rate, abnormal rhythm, high blood pressure, heart attack Dizziness, seizures Extremely high temperature

11 Effects on Adults Long-term Powerful addiction: unable to stop use, tolerance, withdrawal symptoms Neurotransmitters turned off Tremor, uncontrolled movements (Parkinson s Disease) Paranoia, hallucinations,compulsive & aggressive behavior Weight loss Insomnia, memory loss Persistent abnormal heart rhythms, stroke

12 Permanent Effects on Adults After meth is stopped At least 6-12 months of symptoms Profound depression, lack of pleasurable feelings Insomnia Psychosis, paranoia Permanent brain changes Brain scans show up to 80% reduction in Dopamine metabolism

13 Medical Effects on Children Short-Term Same as Adults Symptoms occur at lower doses Long Term Unknown

14 Health hazards in the meth lab Toxic chemicals Red P method Anhydrous Ammonia Method Other health hazards

15 What Toxins Are in a Meth Lab? Red-P Method Methamphetamine powder and solution Flammable solvents Red Phosphorus Acid Lye Iodine

16 Solvents Highly flammable, large quantities Many solvents used: camp fuel, tolulene

17 Solvents Inhalation/aspiration cause pneumonitis, pulmonary edema, death Ingestion may cause liver or bone marrow failure Chronic inhalation causes brain damage

18 Red Phosphorus Inhalation of powder causes respiratory and eye irritation: cough, bronchitis, burning eyes

19 Red Phosphorus When heated with acid, produces LETHAL phosphine gas. Sx s = pulmonary edema, liver and kidney failure, psychosis, sz s, coma There is a better picture of phosphine gas

20 Acids Stored in large quantities in unmarked containers, frequent spills

21 Acids Acid inhalation causes respiratory irritation, skin and mucosal erosion, pulmonary edema, death

22 Lye Severe caustic burns on the skin, eyes, mouth, esophagus (if swallowed)

23 Iodine Concentrated iodine causes irritation and burns to skin, eyes, respiratory tract, mouth, esophagus.

24 Iodine Chronic ingestion can cause diarrhea, vomiting, pain, thyroid disease. Large ingestion can be fatal.

25 What Toxins Are in a Meth Lab? Anhydrous Ammonia Method Methamphetamine powder and solution Flammable solvents Anhydrous ammonia Lye Acid Lithium Sodium

26 Anhydrous Ammonia Stored in large pressurized steel tanks Chemical burns. Severe frostbite with contact from gas as it is released from tanks

27 Anhydrous Ammonia Eye irritation, burns, cataracts Inhalation causes bronchospasm, chest pain, burns, chronic cough, fibrosis, death

28 Lithium Usually extracted from lithium batteries

29 Lithium Ingestion causes abdominal pain, vomiting, diarrhea, tremors, confusion, seizures, coma, kidney failure Ingestion of a small battery usually goes unnoticed until severe symptoms severe gastric ulcers and GI bleeds

30 Sodium Elemental sodium sold in organic solvent, or extracted from lye, stored in unmarked containers Reacts with water to produce highly caustic sodium hydroxide Severe chemical burns to skin, eyes, mouth, esophagus (if swallowed)

31 What Toxins Are in a Meth Lab? New Research John Martyny, Ph.D, Industrial Hygienist National Jewish Medical Center at Denver and NIOSH Measure toxicities Mock meth labs: controlled lab, abandoned house Meth seizures Mock smoked meth

32 New Research Mock Meth Labs Red-P method Lethal phosphine gas level around stove Toxic iodine around cook area Toxic meth level on ALL horizontal and vertical surfaces at cook and down hallway, clothing, toys Toxic levels of hydrochloric acid throughout cook time, some lethal levels

33 New Research Mock Meth Labs Anhydrous Ammonia Method Lethal levels of ammonia throughout cook

34 New Research Controlled smoke of methamphetamine Standard motel room, smoked 2.45 g, none inhaled Toxic meth levels airborne during smoke and on all surfaces after smoke

35 Methamphetamine Itself Implications for Children Method of Intoxication Inhalation Ingestion Consequences

36 Children Are NOT Small Adults Different diet Growing & developing (brain, liver, kidney, lungs); still vulnerable to damage Higher metabolic rate: absorb & metabolize toxins at a higher rate Developing nervous system Unusual habits (i.e. hand-to-mouth behaviors; eating strange things; close to ground/floor; unknowingly imitating; etc.)

37 Even more about the kids Children breathe faster than adults Children have a faster heart beat than adults Children are smaller and closer to the ground than adults They have a heavier exposure to the chemicals due to the above

38 Inhalation/Ingestion Few cases reported in the literature 18 children under 7 years old accidentally ingested methamphatamine. Their parents had left drugs out in easy access Symptoms:Increased heart rate, agitation, irritability and vomiting, muscle breakdown, fever,ataxia, seizure»kolecki, 1998

39 General Abuse and Neglect Issues Physical abuse Sexual abuse Neglect Increased risk for accidents Increased risk for infant mortality

40 Physical Abuse

41 Sexual Abuse

42 Neglect Lack of nurturing and emotional stimulation results in developmental delays, depression and attachment disorder Malnutrition/Failure to Thrive

43 Neglect Poor hygiene and infectious skin conditions (scabies, impetigo) Medical neglect of chronic medical problems (asthma, epilepsy) Little well child care/ Immunization delay No insurance/ Inadequate Medical Care

44 Neglect 2-year old boy found in filthy home with large quantity of meth, parent under the influence

45 Neglect Lack of supervision results in increased injury from falls, burns, lacerations, drowning DUIs increases serious risk for injury from MVA w/wo car seat/ seatbelt Increases risk of injury in house fire

46 Neglect Risk for Accidents 10-month-old female rescued from a house fire in a trailer. Drugs and paraphernalia found in easy access. This infant and 5 year old sibling urine tox meth+

47 Neglect Risk for Accidents Singed hair Also tested positive for methamphetamine

48 Neglect Risk for Accidents Contact burns from falling debris

49 Neglect Associated increased risk of SIDS Associated risk of positional overlay Associated risk of very premature birth and severe complications

50 National DEC Alliance Medical Protocol Decontamination Immediate Within 72 hours Follow-up

51 IMMEDIATE STEPS ON-SITE NATIONAL PROTOCOL FOR MEDICAL EVALUATION OF CHILDREN FOUND IN DRUG LABS LAB SITE ACTIVATE If explosion, obvious chemical exposure, active lab, or child appears ill TRANSPORT IMMEDIATELY VIA EMS NARCOTICS LAW ENFORCEMENT 1. Identify chemicals present 2. Clan lab certified & DEC trained personnel to photograph living conditions and collect evidence 3. Submit data to EPIC and to appropriate databases Within 72 hours Conduct Forensic Interview jointly with CPS DECONTAMINATION per local protocol when medically stable MEDICAL FACILITY 1. Perform Medical Assessment/Screening as per status 1, 2, 3 in Emergency Department 2. Collect Urine via Chain of Custody within 12 hours after removal PLACEMENT per local protocol 1. Complete Medical evaluation: Hepatitis B, C panel if elevated LFT s 2. Dental examination 3. Developmental and Mental Health Evaluation CHILD PROTECTIVE SERVICES Emergency Department 1. Neurological status 2. Respiratory status: O2 sat CXR 3. Blood: CBC Chemistry panel LFT s BUN/Cr 4. Urine toxicology via chain of custody 1. Identify all siblings and obtain tracking information 2. Gather medical history Follow-up Developmental & mental health assessment Update databases Medical follow-up: Within 30 days, 6 mos, 1 yr

52 PERSONNEL DECONTAMINATION Decontamination of the children should occur prior to transport to the medical facility as medically appropriate. Removal of clothing, cleansing of the skin and hair and new clothes are the minimum requirements of decontamination. EMERGENCY ACTIVATION Transport immediately to the ED by emergency personnel if there is an explosion, active chemicals at the scene or the child appears ill i.e. fast breathing, obvious burns, lethargy or somnolence. LAW ENFORCEMENT Immediate 1. Document the quantity and types of chemicals present and document how found i.e. uncapped, in tin cans, so that the exposure of the child can be determined. Document the condition of the home. Document odors and state of lab (actively cooking, decanting stage, drying stage etc.) Document the people at the scene and those who also reside in the home. 2. Personnel on scene should be both clan lab and DEC certified in order to be able to accurately collect, document and photograph the scene as to aid in the child endangerment prosecution i.e. height of chemicals, location of drugs, general state of children, guns, pornography. 3. Collect and submit all the required data for EPIC and/or other data base collection. 4. Transport child as per local DEC protocol in conjunction with CPS. Within 72 hours 1. Children need to be interviewed by personnel trained in the forensically correct method for children. Coordinate this process with CPS. Follow-up 1. Update databases as needed. CHILD PROTECTIVE SERVICES Immediate 1. Assist law enforcement in the collection and documentation of the scene from the child s perspective. Decide who will photograph scene. 2. Transport child as needed to facility as designated in your local DEC protocols. 3. Placement of children in a safe environment as per local protocol. Within 72 hours 1. There may have been other children in the family or home who were not present at the time of the seizure. All children who have lived in the home will need to be examined and their information collected for tracking. 2. The medical histories of the children need to be investigated and documented. Follow-up 1. Input all the gathered information into a database as determined by the local, state and national protocols. NATIONAL PROTOCOL FOR MEDICAL EVALUATION OF CHILDREN FOUND IN DRUG LABS MEDICAL PERSONNEL Immediate 1. Head to toe exam of the children within 2 to 4 hours to ensure medical stability and document any acute findings that might need treatment or change over time. This may occur in an ED, physician s office or by EMT s on scene. This should include but not be limited to a good pulmonary exam, skin exam, neurologic exam and affect (scared, happy, detached). May include observations by EMT s, RN on scene or other personnel to document the affect of the children. 2. Blood test to be obtained include a CBC (anemia, cancers, thrombocytopenias), Chemistry Panel to include BUN/Cr and LFT s (kidney and liver damage, electrolyte imbalances). Can be done acutely or within 72 hours. 3. Collect urine for toxicology. This should happen as soon as possible but must occur within 12 hours for optimal results. Submit to a lab that screens and reports for the level of detection of the test not just at NIDA standards. Chain of Evidence forms may be utilized or usual medical protocols for urine toxicology screens may be followed. Within 72 hours 1. A complete medical evaluation as needed based on the exam done at the first evaluation. 2. Blood test if not done on the earlier exam. 3. Hepatitis B, C panels as indicated if LFT s elevated. 4. Developmental evaluation using an age appropriate standardized tool. 4. Mental health evaluation. 5. Dental evaluation. Follow-Up 1. Repeat medical evaluation in 30 days, 6 months & 1 yr. 2. Follow up developmental evaluations as needed based on the initial evaluations. 3. Follow up mental health interventions and assessments as needed. EMERGENCY DEPARTMENT 1. Complete medical evaluation to assess acute medical needs. 2. Specific attention to the pulmonary exam as the chemicals can cause acute respiratory problems. RR s, O2 saturation and a CXR in the symptomatic child are the minimum required. 3. Blood tests as needed in addition to a CBC, Chemistry Panel to include BUN/Cr and LFTS. 4. Collect urine for toxicology. This should happen as soon as possible but must occur within 12 hours for optimal results. This should be submitted to a lab that screens and reports for the level of detection of the test not just at NIDA standards. Chain of Evidence forms may be utilized or usual medical protocols for urine toxicology screens may be followed.

53 Decontamination Maximal Undress and rinse/wash at scene, all new clothes Medium Undress and wipe off and put on new clothes Do nothing and transport with a covering blanket or suit for off site decontamination Toys/Objects left at scene

54 Medical Exam - Immediate Examination Within 2 to 4 hours Vital Signs Lungs Skin Urine Tox Screen at exposure level Blood Tests - CBC, LFT s, RFT s

55 Blood Tests Complete blood count (CBC) anemia (solvents, nutrition) cancers (solvents) Liver function tests (LFT s) solvents Kidney function tests (BUN, Cr) solvents

56 Urine Tox Screens NIDA levels - work place screening 500 ng/dl-confirmatory level Exposure levels Usually done by lab Reported out only if asked Level down to 50 to 100 ng/dl

57 Collect first urine after leaving scene (when possible as we all know 2 year olds don t urinate on command!)

58 Exam Within 72 hours Comprehensive Medical Exam Developmental Testing Mental Health Assessment Dental Evaluation Further Blood tests if any abnormities on first set

59 Medical Evaluation Follow-Up Repeat Exams in 30 days, 6 months and 1 year Specific medical follow up as indicated by exam findings Follow up developmental evaluations as indicated Follow up mental health evaluation and service

60 QUESTIONS?